An order issued by the Railway Board said the Fishbone technique and other tools like the 5-why analysis would lead to better determination of the root-cause and, thereby, minimising the chances of recurrence.
The Railways has decided to upgrade its accident enquiry process by introducing industry-standard cause and effect analysis techniques like Ishikawa (Fishbone) diagrams and other such tools developed by Japan. An order issued Wednesday by the Railway Board said the Fishbone technique and other tools like the 5-why analysis would lead to better determination of the root-cause and, thereby, minimising the chances of recurrence.
Both these techniques have been developed by Japan and are widely used in different sectors to systematically looking at effects and the causes and fins a solution to a problem.
“The accident enquiry committees should, invariably, carry out Fishbone analysis in all cases of consequential accidents as a part of Accident Enquiry process for identification of the root-cause and recommend corrective measures based on the same.
“Further, in case of SPADS (Signal Passing at Danger), 5-Whys (Why-Why) root-cause analysis may be carried out to improve the incisiveness of the accident investigation. The accident enquiry report approving authority may please be directed to ensure that root-cause analysis techniques as mentioned above are used in respective cases without fail,” the order stated.
It also said that the introduction of these techniques may require training of officers and personnel involved which has to be organised by the railway zones at their end. The Railway Board also said that short courses are being organised by Director General of the National Academy of Indian Railways (NAIR).
These instructions on upgrading the accident enquiry process will become effective from February 1, the order stated. Enquiries into railway accidents are conducted by the Commissioner of Railway Security which comes under the Ministry of Aviation to make it impartial.
